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LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
.Professionals Code, and my License is in full force and effect.
1.License # Lic. Class Exp. Dat6
gate 'e� X Z A je; Signature of Contractor
77-7- —1
-OWNER-BUILDER DECLARATION
1,hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) , , 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code)'. .
I am exempt under Section B&P.C. forthis reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
. ( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ), I have and will maintain workers' compensation insurance, as required by
Sktion 3700 of the Labor bode, for the performance of the work for which this
permit is i ' ssubd. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
I 11"XIV1.12 FU ND 035-91"1- 12"301
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in -the performance of the work for which this permit is issued,
I shall not employ any person. in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall fort ' hwith comply with those Prov, ions.
Date: Applicant—
Vol
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines upto$100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the -Labor Code, interest and attorney's fees. '
IMPORTANT Application is hereby made to the Director of Building and Safety
-ior a permit subject 'to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or. pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information i's
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the. above- mentioned property for inspection purposes.
ig�ature (Ownier/Agent) Date _-!ErL 114ie;
I/S
PERMIT#
BUILDING PERMIT
9%)5414
DATE VALUATION LOT TRACT
.4
JOB SITE
ADDRESS S -5 G'"i D TIUVE IRSE; AVEN UE.
N
OWNER
CONTRACTOR DESIGNER ENGINEER
R,rr Flom, VIVI 1111C
INIC./lUff
P0 WX 9 10
'1425 E, UNWERSM'DRIVE
LA. QUNTA CA. 912-53
P1.40FNIX ',A4 85034
CBIN 4990
USE OF PERMIT
SFD -, PLAN 34R, L0T 24. -flEFA&ITT DOISS NOT IN(MUDE J3LOCK
WAJXS QR P0QL, PLAN CIIECK PORTK)N OF JFPRE Itf-DUCED 751114 F0R
MULTUILE ISIWANCE OF, tiAME PLAIN TIT41.
0J.31'0&1 CONSIMOCTICW Z 6 10. 00 3.1,"
P0RCH/P,A.'ft0 140M0 ;&F
0ARACrWCARPQR:r 498.04 3F
IMA111, IT Of Ca, SURUCTMA,
'D CU _N
21.41941.30
CONS'ndfM10N 101-000-418-0W $1.041-100
KAN CHWX FFF 10 , 14)0-439�118 $214.01
YAJEXA1A%Nt1C*.A-`L FUZ 10.1-000-4211-M . 0
OXCTRICAL FW-', 101 -000-40-000
PL LIN481 NO KX, lot -M-419-000 S180.50.,
IT VOW1 N1,10TI014 Rr-SK) 10 1 -OW741 AW
I 'I Vzi a,
Y
GRIVNING FEE tol-000-42.1-000 $20.
INFRAS�rkucollifwc- 'ME 2254*0-443�-4142 S4,79430
AlCf fN 3- W33.W -101 -WO�255-000 13 Is
S084DTAL CONSTRUCM.0114 AWD KAN C"REWN
%,fP3,48
I.XISS PRE-P.ML)FEE.S
$0A
TUICAW, PERMIT FEWS DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
aw
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION — — — j
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K to Wrap
6
F.A.U.
Framing
0 Inz 1:T
Compressor ;61 -
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final C7 -
Final
POOLS -SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I
Underground PIbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:,
Final '4,
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)